Healthcare Provider Details

I. General information

NPI: 1063593861
Provider Name (Legal Business Name): DR. BRADLEY BRENNECKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6782 GOSHEN RD
GOSHEN OH
45122-9317
US

IV. Provider business mailing address

6782 GOSHEN RD
GOSHEN OH
45122-9317
US

V. Phone/Fax

Practice location:
  • Phone: 513-722-2933
  • Fax: 513-722-2923
Mailing address:
  • Phone: 513-722-2933
  • Fax: 513-722-2923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16397
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: